SEARCHCOHORTmaxillofacial surgery, oral surgery

cohort·maxillofacial surgery, oral surgery, otolaryngology, addiction medicine, infectious disease·PMC10216904

Surgical Treatment in Patients with Toxic Phosphorus Osteonecrosis of Facial Skull Middle Zone

Dentistry Journal · 12 authors, 10 centres

AI SUMMARY

FIDELITY 100%

POPULATION50 patients (41 male, 9 female; age 22–44 years) with toxic phosphorus osteonecrosis of the facial skull middle zone due to desomorphine or pervitin use, treated at I.M. Sechenov University from 2013 to 2016

INTERVENTIONSurgical resection of necrotic bone (partial maxillary resection for Type 1; maxillary resection to zygomatic border via Kocher–Weber approach for Type 2; maxillary + partial zygomatic resection for Type 3; maxillary + zygomatic + orbital floor resection for Type 4), with margins 0.5–1 cm beyond visible osteonecrosis

COMPARISONComparison across four types of disease severity (Type 1: local maxilla involvement, n=15; Type 2: ≥3 teeth involved, n=14; Type 3: maxilla + zygomatic body, n=11; Type 4: maxilla + zygomatic + orbital floor, n=10)

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TL;DR

This study from Sechenov University (2013–2016) examined 50 patients with toxic phosphorus osteonecrosis of the midface caused by desomorphine and pervitin use, classifying them into four types based on disease extent. Surgical resection with margins 0.5–1 cm beyond visible necrosis achieved stable remission in patients who maintained drug abstinence and oral hygiene, with over 50% reporting complete pain relief postoperatively. The findings highlight that radical surgical resection is effective for limited disease and serves as a palliative measure in severe cases, though patient compliance and drug relapse remain major challenges.

Full summary

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{"Background": "Toxic phosphorus osteonecrosis of the facial skull bones has become a significant medical and social problem, particularly in Russia and post-Soviet states, due to the use of artisanal narcotic drugs such as desomorphine ('krokodil') and pervitin. These drugs contain phosphorus, which induces osteonecrosis of the maxilla, zygomatic bone, and orbital floor. Unlike bisphosphonate-related osteonecrosis seen in developed countries, this condition affects younger, socially active individuals (predominantly males of working age) with high rates of comorbid infections (HIV, hepatitis B/C), poor compliance, and severe drug addiction. Patients typically present late with extensive necrosis, fistulas, purulent discharge, and facial deformities. The study aimed to increase the effectiveness of surgical treatment for this patient population.", "Methods": "The study was conducted at I.M. Sechenov University from 2013 to 2016, enrolling 50 patients (41 male, 9 female; sex ratio 4.56:1; age range 22\u201344 years) with toxic phosphorus craniofacial osteonecrosis. Inclusion criteria included age \u226518 years, history of phosphoric narcotic use for >1 year, documented drug remission \u22653 months, and bone disruption for >2 months. Exclusion criteria included lack of compliance, ongoing drug abuse, decompensated comorbidities, drug relapse, voluntary refusal, or history of bisphosphonates/denosumab. Patients were classified into four types: Type 1 (local maxilla, 1\u20132 teeth, n=15, 30%), Type 2 (maxilla \u22653 teeth, n=14, 28%), Type 3 (maxilla + zygomatic body, n=11, 22%), and Type 4 (maxilla + zygomatic + orbital floor, n=10, 20%). Preoperative preparation included professional hygiene and antiseptic oral washing 3\u20134 times daily for 1 week. Pain was assessed using the 11-point Numerical Rating Scale (NRS). Radiological evaluation included skull radiography, panoramic radiography, and CT. Surgical resection removed all necrotic bone 0.5\u20131 cm beyond visible borders. Statistical analysis used R version 4.2.2, with significance at p<0.05, employing Chi-square, Fisher's exact, and Kruskal\u2013Wallis tests.", "Key Results": "Pain intensity escalated with disease severity: 33.3% of Type 1 patients reported no pain versus 0% of Type 4 patients; 80% of Type 4 patients reported unsufferable pain versus 6.8% of Type 1 (p<0.05). Radiographically, demarcation lines were present in the maxilla in 100% of all types, in the zygomatic bone in 0% (Type 1), 28.6% (Type 2), 100% (Type 3), and 100% (Type 4), and in the orbital floor only in Type 4 (100%). Sequestra were present in 40% (Type 1), 28.6% (Type 2), 45.5% (Type 3), and 80% (Type 4) (p<0.05). Cortical plate sclerosis and periosteal reaction were present in 100% of all types. In the early postoperative period, swelling peaked at day 2\u20133 and decreased over 5\u20137 days. Suture line disruption occurred in 6 patients (12%), primarily in Type 3. In the late postoperative period (1 month\u20132 years), 66.7% of Type 1 patients reported no pain versus 10% of Type 4 (p<0.05). No patients in any group reported very intense or unsufferable pain in the late period. Among patients who maintained drug abstinence and hygiene, steady remission was achieved with no osteonecrosis spread. However, 3 patients (6%) died from drug overdose.", "Clinical Implications": "Radical surgical resection with margins of 0.5\u20131 cm beyond visible necrosis is effective for treating toxic phosphorus osteonecrosis, particularly in limited disease (Type 1\u20132), where complete pain relief was achieved in over 50% of cases. For severe disease (Type 4), surgery serves as a palliative measure with satisfactory results. The study underscores that successful outcomes depend critically on patient compliance, including sustained drug abstinence and oral hygiene, as relapse leads to disease progression to the cranial base. The high rate of comorbid infections and low compliance necessitates a multidisciplinary approach involving surgeons, narcologists, and infectious disease specialists. Limitations include the lack of a control group (not ethically feasible), no subgroup analysis by infectious disease status, age, or sex, and significant loss to follow-up beyond 2 years."}

PICO

PPOPULATION

50 patients (41 male, 9 female; age 22–44 years) with toxic phosphorus osteonecrosis of the facial skull middle zone due to desomorphine or pervitin use, treated at I.M. Sechenov University from 2013 to 2016

IINTERVENTION

Surgical resection of necrotic bone (partial maxillary resection for Type 1; maxillary resection to zygomatic border via Kocher–Weber approach for Type 2; maxillary + partial zygomatic resection for Type 3; maxillary + zygomatic + orbital floor resection for Type 4), with margins 0.5–1 cm beyond visible osteonecrosis

OOUTCOME

Pain reduction (NRS), cessation of suppuration, absence of bone exposure, radiographic remission, suture line disruption (6 patients, 12%), fatal drug overdose (3 patients, 6%)

STUDY TYPE

cohort

SPECIALTY

maxillofacial surgery

SUMMARISED BY

AI pipeline

FIDELITY CHECK

100% · A

ORIGINAL PAPER

PMC10216904

Surgical Treatment in Patients with Toxic Phosphorus Osteonecrosis of Facial Skull Middle Zone

Dentistry Journal

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ABSTRACT

Abstract During the last few years, in the territory of the Russian Federation, the number of cases of toxic phosphoric osteonecrosis of the jaws has increased against the background of taking drugs of “artisanal” production (pervitin, desomorphin). The aim of our study was to increase the effectiveness of surgical treatment of patients with a diagnosis of toxic phosphorus necrosis of the maxilla. We performed a comprehensive treatment of patients with a history of drug addiction and the above diagnosis. Surgical intervention in the volume of complete resection of pathologically altered tissues and reconstructive techniques using local tissues and a replaced flap made it possible to achieve good aesthetic and functional results in the early and late postoperative period. Thus, our proposed method of surgical treatment can be used in similar clinical situations. Keywords: osteonecrosis of the jaws, maxilla, zygoma, orbit, substance related disorder, margins of excision, krokodil, desomorphine

CITATION EXPORT

Davit H Ispiryan, Gagik Hakobyan, Anastasia Li et al.. Surgical Treatment in Patients with Toxic Phosphorus Osteonecrosis of Facial Skull Middle Zone. Dentistry Journal. (2023). https://doi.org/10.3390/dj11050108

AUTHORS

12 · 10 CENTRES

Davit H Ispiryan, Gagik Hakobyan, Anastasia Li, Ekaterina Yu Diachkova, Yuriy Vasil’ev, Artur Kheygetyan, Elena Ivanova, Kirill Zhandarov, Natalia Kireeva, Roman Safronov, Alexey Serikov, Yuri A Medvedev

1Department of Maxillofacial Surgery, I.M. Sechenov First Moscow State Medical University (Sechenov University), 121059 Moscow, Russia
2Department of Oral and Maxillofacial Surgery, Yerevan State Medical University, Yerevan 0025, Armenia
3Department of Oral Surgery, I.M. Sechenov First Moscow State Medical University (Sechenov University), 121059 Moscow, Russia
4Department of Operative Surgery and Topographic Anatomy, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119435 Moscow, Russia
5Dentistry Department No.1, Rostov State Medical University, 344022 Rostov-on-Don, Russia
6Department of Oral Surgery and Implantology, Vladimirsky Moscow Regional Research Clinical Institute, 129110 Moscow, Russia
7Department of Therapeutic Dentistry, FGBOU DPO RMANPO of the Ministry of Health of Russia, 125993 Moscow, Russia
8Department of Outpatient Therapy, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119333 Moscow, Russia
9Department of Physical Education, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119121 Moscow, Russia
10Department of Maxillofacial Surgery and Traumatology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia